Fisher, Betty J 5.?
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Betty Jean Fisher Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/30/2017 92 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
SI Manner of Death Le Natural Cause 0 Accident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
er
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 97
['Burial Date Cemetery or Crematory
07/31/2017 Pine View Crematory
El Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
4. Hold
F Date Point of
j ❑Transportation Shipment
by Common Destination
Carrier
t..
Disinterment Date Cemetery Address
-_ Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
A.
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
4.01
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
is*
i
® Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/31/2017 Registrar of Vital Statistics Caroline 00Bar6er 'ErectronuatrySigned
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
s Date of Disposition 8 I /7 Place of Disposition py,eu, G/8in-r 7
i // (address)
N# (section) (lot numbe) (grave number)
t 1
Name of Sexton or P arge of Premises —J9n.Ii G-✓i &e.,o't t.4-e
(please plrint)
1.1
Signature c Title �� w��
(over)
DOH-1555 (02/2004)